Gastroentrology Flashcards
Chron’s disease (IBD)
- autoimmune, inflammatory disease
Clinical:
- RLQ pain
- non-bloody diarrhea
- weight loss
Diagnosis:
1. UGI-series —> shows string sign
2. Colonoscopy —> shows discontinuation of inflammation (skip lesions) + cobblestone appearance
3. Biopsy —> 1. Transmural inflammation; 2. Non-caseating granulomas; 3. Creeping fat
4. Laboratory—> ASCA (antibody); B12 & iron deficiency
Treatment:
1. Mild disease —> 5-ASA (mesalamine) or glucocorticoids
2. Severe or refractory disease—> immunosuppressant (methotrexate, infliximab)
3. Surgery —> is not curative, only palliative
Complication:
- fistula, abscess, strictures ( bowel obstruction)
Note:
-mesalamine targets the small bowel & right side of colon
- completely diverse ( any segment of GI from mouth to anus)
-Completely deep ( transmural, through all layers of mucosal membrane)
-Completely dry ( normally non-bloody, or dry stool)
-Completely discontinuous ( skip lesions)
Ulcerative colitis (IBD)
- affect mucusal & submucosal layers
- limited to colon only
- rectum is always involved
- continuous inflammation
- intermittent colonic inflammation
Clinical:
- chronic abdominal pain
- bloody diarrhea
- systemic system ( fever, fatigue)
- bloody diarrhea + abdominal pain + fecal incontinence
- LLQ pain
- tenesmus : incomplete bowel emptying
- severe cases= toxic megacolon, fever, increased ESR
- complication:
1. more at risk for colon cancer
2. Primary sclerosing cholangitis (PSC)
Diagnosis:
- Flexible sigmoidoscopy —> ulceration/ continuous inflammation
- barium enema: complete loss of haustral marking “ lead-pipe/ stove pipe sign”
- laboratory: p-ANCA
Treatment:
- topical 5-ASA (mesalamine) as first line
- glucocorticoid can be used in more severe cases
- surgical resection in severe/refractory cases can be curative
- offer screening colonoscopy (8-10 years) after initial diagnosis, then after 1-3 years thereafter
Note:
ULCER: usually limited to colon especially rectum
Hepatitis (general)
- in all types of hepatitis, the history & exam are the same
Clinical:
- systemic symptoms: fever, malaise, N/V
PE:
- jaundice
- hepatomegaly
- RUQ pain/tenderness
- clay colored stool
Laboratory:
- elevated LFT ( AST, ALT, Bilirubin) in acute & chronic hepatitis
Fulminant hepatitis:
- acute hepatic failure in patient with hepatitis
- liver is failing within days or weeks
- only definitive treatment is liver transplant
Note:
- hepatitis A: anus
- hepatitis B: baby/bodily fluid
- hepatitis C: chronic infection
- hepatitis D: dependent on hepatitis B infection
- hepatitis E: embryo (pregnancy dangerous develop fulminant hepatitis)
Hepatitis A
- viral infection
- transmission: fecal-oral route ( contaminated food/water, daycare workers, international travel)
Clinical:
- asymptomatic
- mild symptoms (fever, malaise, N/V) ( jaundice, hepatomegaly, RUQ tenderness)
Diagnosis:
- elevated LFT ( AST & ALT IN 1000’s = acute; in 100’s = chronic ) ( bilirubin)
- IgM anti-HAV ( acute infection)
- IgG anti-HAV ( chronic or past infection)
Treatment:
- mostly supportive—> rest, acetaminophen, fluid
- hepatitis A vaccine & immunoglobulin for prevention & post-exposure prophylaxis
- very rare to progress to chronic or fulminant hepatitis (only acute infection)
Hepatitis B
- viral infection that can be acute or chronic infection
- rare fulminant hepatitis
- minimal chronic hepatitis
Transmission
- from mother to baby ( perinatal or vertical transmission)—> high prevelance countries
- from bodily fluid ( sexual, IV drug) —> low prevalence countries (USA)
Clinical:
- 30% present with jaundice (icteric phase)
- 70% present with no jaundice ( anicteric phase)
- fever, malaise, N/V
Diagnosis:
- elevated LFT ( AST, ALT, Bilirubin)
- serology:
1. IgM anti-HBc ( acute infection)
2. IgG anti-HBc (Chronic infection)
3. Hepatitis B surface antiBody (anti-HBc)
- hepatitis B vaccine/ booster
- beat hepatitis B, it has resolved
4. Hepatitis B surface antiGen (HBsAg)
- they Got hepatitis B, have to decide if it is acute (positive IgM) or chronic (positive IgG)
Examples:
1. If a positive hepatitis B surface antibody ( positive anti-HBc):
- have booster or body beat the infection
- if only positive anti-HBc —> patient have hepatitis B vaccine
- if positive anti-HBc + positive IgG = They beat it (resolved infection)
- If a positive hepatitis B surface antigen ( HBsAg):
- acute (positive IgM) or chronic (positive IgG)
Treatment:
- acute: supportive (rest, acetaminophen, fluid)
- chronic: antiviral agent ( Entecavir, Lamivudine, Tenofovir)
- hepatitis B vaccine at 1-2 months after birth, than 6 months
Hepatitis C
- Hepatitis C progress to chronic stages in up to 85% pf patient
- up to 30% of patients with hepatitis C will develop Cirrhosis in a 20-30 year period
- in the US, hepatitis C is the most common cause of chronic liver disease, & the most common reason a patient needs a liver transplant
Transmission:
- percutaneous exposure to infected blood ( IV drug users) —> in the USA
Clinical:
- asymptomatic
- symptomatic: ( fever, malaise, anorexia, jaundice, clay colored stool, dark urine)
Diagnosis:
- screening: HCV antibody ( positive in acute, chronic, past infection; not specific)
- confirmation: HCV-RNA test (PCR test)
Treatment:
- antiviral agents:
1. Ledipasvir + sofosbuvir
2. Glecaprevir + pibrentasvir
Hepatitis D
-Hepatitis D cannot exist without hepatitis B infection
Transmission:
- exposure to infected blood ( IV drug users)
Clinical: same as previous
Diagnosis:
- screening: anti-HDV antibody
- confirmation: HDV-RNA (PCR TEST)
Treatment:
- asymptomatic, normal ALT = Observation
- symptomatic, elevated ALT= interferon alpha (antiviral)
- prevention: hepatitis B vaccine
Hepatitis E
- self resolving + patient have mild symptoms—> unless patient is pregnant, can develop fulminant hepatitis, increased mortality rate
transmission:
- fecal-oral route (like hepatitis A)
CLINICAL:
- fever, malaise, N/V, abdominal pain , jaundice
Diagnosis:
- elevated LFT
- Anti-HEV antibody
Treatment:
- supportive, unless patient is pregnant
Stool osmotic gap
SOG:
290 - 2 * ( Stool Na + Stool K)
Findings:
- secretory diarrhea: < 50
- indeterminant: 50-125
- osmotic diarrhea: > 125
Note:
- osmotic diarrhea: polyethylene glycol, sorbitol, lactose ( diarrhea after ingestion of agent, and does not occur while fasting)
- secretory diarrhea: vibrio, VIPoma, cystic fibrosis, post-surgical patients with bile acid ( diarrhea happens while fasting & at night)
- factitious diarrhea: due to laxative abuse + signs of volume depletion ( lightheadedness, tachycardia, hypotension)
Giardiasis
Transmission:
- contaminated food/water
- daycare, nursing home
- immunodeficiency ( cystic fibrosis, HIV, IgA deficiency)
Pathology:
- loss of brush border enzymes —> malabsorption
Clinical:
- subacute (< 4 weeks), chronic ( months)
- loose, oily, non-bloody stool + foul smelling
- bloating
- weight loss
- vitamin deficiency
Diagnosis:
- stool antigen or PCR testing
- stool microscopy
Treatment:
- 1st line: tinidazole or nitazoxanide
- children: metronidazole
- pregnancy ( 1st trimester): paromomycin
- refractory: evaluation for immunodeficiency
Sarcoidosis
- multi-system inflammatory non-caseating granulomatous formation. ( mediastinum fullness + bilateral reticulonodular opacities)
- subclinical (asymptomatic) hepatic involvement
- LFT: mixed cholestatic & hepatocellular pattern
Significant symptoms:
- hilar lymphadenopathy
- erythema nodosum
- facial nerve palsy
- hepatosplenomegaly
- asymptomatic LFT abnormalities
- hypercalcemia
- parotid gland swelling
Diffuse esophageal spasm
Symptoms:
- intermittent chest pain ( few seconds to minutes)
- dysphagia for food & liquids
Diagnosis:
- manometry: Intermittent peristalsis, multiple simultaneous contraction
- Esophagram: corkscrew pattern
Treatment:
- CCB
-Nitrates or tricyclic
Upper GI bleed
Symptoms:
- hematemesis + melena + anemia + BUN/CR ratio > 20
Measures:
1. Supplemental oxygen
2. Bowel rest
3. IV-fluid through large bore catheter
4. PPI (for acid suppression)
5. Packed RBCs transfusion ( increase O2- carrying capacity in patient with significant low Hg level < 7 )
Splenic infarction
- LUQ pain + fever + leukocytosis
- associated with:
1. Hyper-coagulable states: (SLE = via ANA antibody = young, joint pain, thrombocytopenia), (malignancy)
2. Embolic disease (atrial fibrillation, endocarditis = MR, atheroma)
3. Hemoglobinopathy ( sickle cell disease; hemoglobin electrophoresis)
Non-alcoholic fatty liver disease (NAFLD)
- hepatomegaly + mild elevation in transaminase ( AST/ALT < 1)
- associated with metabolic syndromes (central obesity, diabetes, hyperlipidemia, HTN)
- tx: weight loss + control of metabolic risk factor
- due to insulin resistance & increased peripheral lipolysis & increased triglyceride synthesis —> increased accumulation of free fatty acids
Autoimmune hepatitis
Signs:
- elevated AST & ALT ( 100-1000)
- elevated total bilirubin
- mildly elevated ALP
- arthralgia + anorexia + fatigue
- positive anti- smooth muscle
Findings:
- portal & periportal lymphoplasmacytic infiltration
Signs:
- N, fatigue, pruritis, jaundice
Tx:
- prednisone with/without azathropine
Hemochromatosis
Signs:
- elevated AST & ALT
- associated with diabetes (heart failure, cirrhosis, hypogonadism, arthritis)
- after menopause in women
- arthralgia + hyperpigmentation + fatigue
Primary biliary cholangitis (PBC)
- destruction of intra-hepatic bile duct
- lead to cholestatic disease ( markedly elevated ALP)
- fatigue + pruritus
Hepatic encephalopathy
Symptoms:
- mental status change
- sleeping pattern change
- flapping tremor
- ataxia + slurred speech
Associated with:
- diarrhea, sedatives, narcotics, hypokalemia, GI bleeding, TIPS, bacterial peritonitis, UTI, pneumonia
Tx:
- fluid, antibiotics (treat cause)
- lactulose, lactitol, rifaximin ( decrease blood ammonia concentration)
Viral hepatitis
Signs:
- ALT > AST in 1000
- increase bilirubin
- N/V
Alcohol liver disease
Symptoms:
- AST/ALT ratio ( almost 2)
- AST is rarely > 300
- AST is usually higher than ALT by a factor of 2
- gives a shrunken liver or non-palpable liver edge
Acalculous cholecystitis
- elevated ALP & bilirubin
Ischemic hepatic injury (liver shock)
- is associated with surgery, hemorrhage, hypotension
- lead to increase AST & ALT in 1000
- mild increase in bilirubin & ALP
- liver enzyme goes to normal within a week
Acute liver failure
- acute liver failure after hepatitis within 7 days
- common cause viral hepatitis & drug toxicity
- diagnosis of acute liver failure —> signs of hepatic encephalopathy (ALT & AST > 1000 + Mental status change, tremor, sleep change, ataxia + liver dysfunction INR> 1.5)
Cirrhosis
- should be suspected in any patient with chronic liver disease ( ascites, spider angiomata, gynecomastia, splenomegaly).
- causes of chronic liver disease:
1. Viral hepatitis
2. Chronic alcohol abuse
3. Nonalcoholic fatty liver disease
4. Hemochromatosis
Management of cirrhosis
- LFT monitor ( INR, Bilirubin, albumin)
- Compensated:
- US: for hepatocellular carcinoma ± alpha-fetoprotein every 6 months
- EGD varices (surveillance) - Decompensated:
- Assess complication
2.1 variceal hemorrhage:
- start non-specific BB
- repeat EGD every year
2.2 ascites
- dietary sodium restriction
- diuretics
- paracentesis
- abstinence from alcohol
- Hepatic encephalopathy
- fluid + antibiotics for causative agent
- lactulose therapy
Wilson disease
Autosomal recessive mutation (ATP7B) —> hepatic copper accumulation —> deposit in basal ganglia/ cornea
Tx:
- chelators ( D-penicillamine, trientine)
- zinc
Primary biliary cholangitis (PBC)
- Autoimmune destruction of intra-hepatic bile duct
Clinical:
- affect middle-aged women
- fatigue & pruritus
- hepatomegaly, jaundice, ascites
- eyes exanthoma
Diagnosis:
- elevated ALP & bilirubin
- positive anti mitochondrial antibody
- elevated hyperlipidemia
Treatment:
- ursodeoxycholic acid (UDCA) (delay progression)
- liver transplant ( severe cases)
Complication:
- hepatocellular carcinoma
- ADEK vitamin deficiency
- metabolic bone disease ( osteoporosis, osteomalacia)
Evaluation of Alkaline phosphatase (ALP)
- elevated serum ALP
- check GGT:
- Normal GGT —> bone origin (paget’s disease)
- Elevated GGT —> biliary obstruction origin2.1 check RUQ via US + Antimitochondrial antibody (AMA)
2.1.1 normal (US & AMA) —> consider liver biopsy, ERCP, observation
2.1.2 dilated bile duct —> ERCP2.1.3 positive AMA or abnormal hepatic parenchymal on US —-> Liver biopsy
Stain-induced hepatocellular injury
- lead to elevated ALT & AST
Gilbert syndrome
- inherited disorder of bilirubin metabolism
- decrease conjugation of bilirubin
Clinical:
- recurrent episodes of jaundice ( —> scleral icterus)
- provoked by: surgery, fasting, dehydration, stress ..
Diagnosis:
- increase indirect bilirubin (total bilirubin)
- normal ALT, AST, ALP
Treatment:
- benign, no treatment required.
Note:
-Elevated total bilirubin = indirect bilirubin
Acute cholangitis
- ascending infection due to biliary obstruction
Clinical:
- charcot triad: fever, jaundice, RUQ pain
- Reynold pentad: hypotension + altered mental status
Diagnosis:
- cholestatic liver function abnormalities —>
1. Elevated bilirubin & ALP
2. Mildly elevated ALT & AST
- biliary dilation on US or CT
3. Leukocytosis with left shift
Treatment:
- antibiotic coverage of enteric bacteria
- biliary drainage by ERCP within 24-48 hours
Evaluate hyperbilurubinemia
- Elevated unconjugated bilirubin ( indirect)
- hemolysis, Gilbert, drugs, portosystemic shunt
- Elevated conjugated bilirubin (direct)
- With normal ALT, AST, ALP —> Dubin-Johnson syndrome (liver biopsy = dark liver + pigmented hepatocytes + no treatment + impaired bilirubin excretion) , Rotor syndrome (normal liver biopsy
- With elevated ALT, AST—>
- alcoholic hepatitis
- viral hepatitis
- autoimmune hepatitis
- ischemic hepatitis
- hemochromatosis
- toxin/drug- induced hepatitis - With elevated ALP—> check with ultrasound & AMA antibody
- Primary Biliary Cholangitis (PBC)
- Primary Sclerosing Cholangitis (PSC)
- choledocholithiasis
- malignancy (pancreas, ampullary)
- Cholingiocarcinoma
- cholestasis of pregnancy
C. Difficile colitis
Risk factors:
- inflammatory bowel disease ( CD, UC)
- Age > 65
- recent antibiotic use or hospitalization
- chemotherapy
- use of PPI, H2 blocker
Clinical:
- profuse watery diarrhea + Foul-smelling
- leukocytosis > 15,000
- fulminant colitis + toxic megacolon
Diagnosis:
- stool PCR for C. Difficile
- stool Enzyme immunoassay (EIA) & Glutamate Dehydrogenase antigen (GDG)
Treatment:
- hand hygiene
- contact isolation
- bleach to disinfect
- vancomycin ( 4 times a day, for 10 days)
Microscopic colitis
Clinical:
- water, non-bloody diarrhea, fecal urgency/incontinence
- abdominal pain, fatigue, weight loss, arthralgias
TriggerS:
- smoking
- drugs ( NSAIDS, PPI, SSRI)
Diagnosis:
- colonoscopic biopsy —> lymphatic infiltration of lamina propria
1. Collagenous: thickened sub-epithelial collagen band
2. Lymphocytic: high level of intra-epithelial lymphocytes
Management:
- remove possible trigger
- anti-diarrhea medication + budesonide
Microscopic colitis
Clinical:
- water, non-bloody diarrhea, fecal urgency/incontinence
- abdominal pain, fatigue, weight loss, arthralgias
- affect women > 60.
TriggerS:
- smoking
- drugs ( NSAIDS, PPI, SSRI)
Diagnosis:
- colonoscopy—> normal colon mucosa
- colonoscopic biopsy —> lymphatic infiltration of lamina propria
1. Collagenous: thickened sub-epithelial collagen band
2. Lymphocytic: high level of intra-epithelial lymphocytes
Management:
- remove possible trigger
- anti-diarrhea medication + budesonide
Whipple disease
- caused by: bacillus Tropheryma whippellii
- lead to multi-system illness
Clinical:
- men 40-60
- GI: abdominal pain, diarrhea (foul-smelling) , weight loss, steatorrhea, malabsorption with distention
- arthralgia
- chronic cough
- lympadenopathy + hyperpigmentation
- diastolic murmur ( regurgitation)
Diagnosis:
- positive PAS material
Whipple disease
- caused by: bacillus Tropheryma whippellii
- lead to multi-system illness
Clinical:
- men 40-60
- GI: abdominal pain, diarrhea (foul-smelling) , weight loss, steatorrhea, malabsorption with distention
- arthralgia + chronic cough
- lympadenopathy + hyperpigmentation
- diastolic murmur ( regurgitation)
Diagnosis:
- positive PAS material
Diverticulosis
- most common cause of GI- bleeding in adults
- bleeding is typically painless + associated with lightheadedness + hypotension ( hemodynamic instability)
- diverticular hemorrhage usually resolves spontaneously, but occasionally required endoscopy or surgical intervention.
Carcinoid syndrome
- neuroendocrine tumors
- present in distal small intestine, proximal colon, lungs —> with strong metastasis to the liver
- tumor secretes several products ( histamine, serotonin, VIP= all metabolized in the liver)
- in patient with liver metastasis, these products are secreted directly in the systemic circulation —> leading to carcinoid syndrome.
Clinical:
- skin: flushing, telangiectasia, cyanosis
- GI: diarrhea, cramping
- cardiac: valvular lesion (right > left)
- pulmonary: bronchospasm
- niacin deficiency: dermatitis, diarrhea, dementia
Diagnosis:
- elevated urinary 5-HIAA
- CT/MRI of abdomen & pelvis to localize tumor
- octreoScan to detect metastasis
- ECHO: if symptoms of carcinoid heart is present
Treatment:
-Octreotide for symptomatic patients & prior to surgery & anesthesia
- surgery for liver metastasis
Carcinoid syndrome
- presents with: episodic flushing, secretory diarrhea, wheezing, & murmur of tricuspid regurgitation.
- neuroendocrine tumors
- present in distal small intestine, proximal colon, lungs —> with strong metastasis to the liver
- tumor secretes several products ( histamine, serotonin, VIP= all metabolized in the liver)
- in patient with liver metastasis, these products are secreted directly in the systemic circulation —> leading to carcinoid syndrome.
Clinical:
- skin: flushing, telangiectasia, cyanosis
- GI: diarrhea, cramping
- cardiac: valvular lesion (right > left)
- pulmonary: bronchospasm
- niacin deficiency: dermatitis, diarrhea, dementia
Diagnosis:
- elevated urinary 5-HIAA
- CT/MRI of abdomen & pelvis to localize tumor
- octreoScan to detect metastasis
- ECHO: if symptoms of carcinoid heart is present
Treatment:
-Octreotide for symptomatic patients & prior to surgery & anesthesia
- surgery for liver metastasis
Chronic mesenteric ischemia
- patient present with unexplained chronic abdominal pain, weight loss, food aversion. Most cases due to celiac or superior mesenteric arteries.
Risk factors:
- Atherosclerosis (smoking, dyslipidemia)
Clinical:
- crampy, epigastric pain with eating
- food aversion ( Nausea with specific food) & weight loss
-pain is diffused
Diagnosis:
- signs of malnutrition + abdominal bruits
- CT angio, or Doppler US
Management:
- risk reduction ( tobacco reduction), nutritional support
- Endovascular or open surgical revascularization
- pain with eating
- bloating, N, diarrhea
- weight loss
- history of inferior MI, drug-eluting stent
Crohn’s disease
- associated with Ophthous ulcers, skin tags & fistula
- transmural inflammation & non-caseating granulomas
Clostridium septicum associated with colon cancer
- patient with C. Septicum bacteremia require screening colonoscopy
- bacteremia with group D strep. (Strep bovis) also linked to colon cancer
Diverticular disease
Diverticulosis:
- increase intralaminal pressure leading to herniation ( at vesa recta)
- no symptoms ( chronic constipation)
Diverticular bleeding
- injury to exposed vasa recta
Diverticulitis:
- increase intralaminal pressure + trapped food particles + causing microperforation
- LLQ pain + fever + N/V
Risk factor:
- diet high in red meat + fat + low in fiber + NSAIDS + aspirin
- obesity, physical inactivity, smoking
Irritable bowel syndrome (IBS)
- Recurrent abdominal pain + altered bowel habits ( constipation or diarrhea) + symptoms worsen or improve with defecation
Rome 4 diagnostic criteria:
- recurrent abdominal pain/discomfort > 1 day/week for the past 3 months & > 2 of the following:
1. Related to defecation ( improves or worsen)
2. Change in stool frequency
3. Change in stool form
Alarm features:
1. older age onset > 50
2. GI bleeding
3. nocturnal diarrhea
4. worsening pain
5. unintentional weight loss
6. iron deficiency anemia
7. elevated CRP
8. positive fecal lactoferrin or calprotectin
9. family history of early colon cancer or IBD
MANAGEMENT:
- CBC + serology for celiac disease + inflammatory markers
- reassurance + fiber supplement for constipation + anti-diarrhea for diarrhea
Classify bilirubin
Total bilirubin
- Direct = conjugated = urinary excreted ( water soluble)
- indirect = unconjugated = water insoluble = dont show in urine
Acute pancreatitis
Criteria for pancreatitis:
- severe epigastric pain radiates to the back
- elevated lipase or amylase (>3 times of normal limit)
-CT suggest inflammation of pancreas (peri-pancreatic fluid & fat standing) - others:
1. ALT > 150 —> suggest gallstone pancreatitis
2. Severe disease: fever + tachypnea, hypoxemia, hypotension
3. Xanthoma ( fat deposition in arm & shoulder= yellow plaques; associated with hypertriglycerride > 1000; check with fasting serum lipid profile)
Signs:
- fever + N/V+ pain at epigastric region, radiates to the back + diffuse tenderness + mild distention
Acute pancreatitis risk factors:
1. Chronic alcohol use
2. gallstone
3. hypertriglyceride ( when triglyceride > 1000):
- pregnant women with high Trygleceride —> assess via lipid panel —> indicates the need for insulin infusion ( insulin + dextrose to prevent hypoglycemia) or aphaeresis
- drug-induced pancreatitis:
- diuretics ( furosemide, thiazide)
- drugs for IBD ( sulfasalazine, 5-ASA)
- immunosuppressive agents (azathioprine)
- HIV-related medication ( didanosine, pentamidine)
- antibiotics ( metronizadole, tetracycline, isoniazid, TMP-SMX)
- anti-seizure: valproic acid
- ACE Inhibitor (enalapril), statin (simavastatin) - Infection ( CMV, legionella, aspergillus)
- Iatrogenic ( post - ERCP, ischemic/ atheroembolic)
Complication:
- pleural effusion
- ileus
- pancreatic pseudocyst/ abscess/ necrosis ( fluid filled with fibrous capsule that takes 3-4 weeks to develop after acute pancreatitis)
- acute respiratory distress syndrome
Management: ( recover in 3-5 days)
- aggressive IV hydration
- pain control
- bowel rest, than diet advancement as tolerated
Cholesterol embolism
- can occur after a vascular procedure ( cardiac catheterization)
- lead to:
- Skin complication: livedo reticularis, blue toe
- GI complication: mesenteric ischemia, acute pancreatitis
- acute pancreatitis from uncorrectable causes ( ischemia, atheroembolism) can be managed conservatively with analgesia & IV-fluid
Causes of drop in hemoglobin
- enlarged spleen
- hemolysis
- porphyria
- sickle cell disease
- thalassemia
- Upper or lower GI bleed
Chronic pancreatitis
- chronic pancreatitis is inflammatory disease that leads to pancreatic fibrosis
-epigastric pain that radiates to the back & worsen with meals; pain is initially intermittent, but can become constant in advanced disease.
Risk factors:
- recurrent episode of acute pancreatitis
- alcohol & smoking
- family history ( hereditary pancreatitis)
- cystic fibrosis ( in children)
- ductal obstruction ( malignancy, stones)
- autoimmune
Symptoms:
- chronic epigastric pain with intermittent pain-free periods
- malabsorption: weight loss, diarrhea/steatorrhea, (ADEK vitamin) deficiency
- diabetic mellitus
Laboratory:
- amylase & lipase can be normal & un-diagnostic
- CT or MRCP show calcification, dilated ducts & enlarged pancreas
- low fecal elastase
Treatment:
- pain management
- alcohol & smoking cessation
- pancreatic enzyme supplement
Signs:
- postprandial abdominal pain that is not improved with medication ( PPI)
- steatorrhea = bulky, postprandial diarrhea that is difficult to flush
Pancreatic adenocarcinoma
Risk factors:
- smoking
- chronic pancreatitis ( if symptoms worsen with treatment)
- hereditary pancreatitis
-obesity & lack of physical activity
Clinical:
- systemic symptoms ( weight loss, anorexia)
- abdominal pain/back pain (worse at night, with eating, & supine position)
- Jaundice ( in head, vs no in body/tail)
Laboratory:
- cholestasis ( increase ALP & bilirubin)
- increase CA 19-9
- Ultrasound ( if jaundice, head) or CT ( not jaundice, body/tail)
Pancreatic adenocarcinoma ( Head vs. body/tail)
cancer of the head of pancreas:
1. present with jaundice ( elevated ALP & bilirubin, common bile duct obstruction)
2. steatorrhea
3. ultrasound ( to rule out other causes of bile duct obstruction —> choledocholithiasis)
4. epigastric pain
Cancer of the body/ tail:
1. do not present with obstructive jaundice
2. CT with contrast
3. present with constant back pain that is worsen when laying supine
Pancreatic cancer:
1. Smoking history, weight loss, insidious back pain , normal neurologic & x-ray findings —> pancreatic cancer in the tail
CT scan of abdomen in Acute pancreatitis
Confirmed with:
- severe epigastric pain radiates to the back + increased amylase/lipase > 3 times of normal limit
CT Only performed in:
- unclear diagnosis
- fail to improve with conservative management ( maybe chronic, maybe adenocarcinoma)
Acute pancreatitis complicated by hypotension
- thought to arise from intravascular volume loss secondary to local & systemic vascular endothelial injury
- this causes vasodilation, increased vascular permeability & plasma leak into the retroperitoneum, capillary leak, shock & associated organ damage—> result in systemic hypotension
- acute severe pancreatitis progress to severe multi-system organ failure:
- Shock: low BP, high HR
- Renal failure: BUN/Cr > 20 , low urine output
- Early respiratory failure: crackles
- clinical markers to increase suspicion for severe pancreatitis:
1. Age> 75
2. Alcoholism
3. Obesity
4. CRP > 150 AT 48 hours
5. Increase BUN/Cr in the first 48 hours
Diagnosis of acute severe pancreatitis:
- CT or MRCP —> Look for pancreatic necrosis & extra-pancreatic inflammation
Duodenal ulcers
Symptoms:
- epigastric pain that improves with food & worsen with empty stomach
- caused by: NSAIDs or H.pylori
Diagnosis of H.pylori-induced DU:
- endoscopic biopsy or urea breath test
Management of H.pylori-induced DU:
1. PPI (omeprazole or pantoprazole)—> acid suppression
&
2. Amoxicillin + clarithromycin —> antibiotic eradication
Gastric ulcer
Symptoms:
- epigastric pain Worse with food
Complication:
- lead to malignant ulceration
Acute erosive gastropathy
- Aspirin —> reduce protective prostaglandin production
- Cocaine —> vasoconstriction, reducing gastric blood flow
- Aspirin & alcohol —> direct mucosal injury
Symptoms:
-hematemesis + abdominal pain
Esophageal disorders
- Diffused esophageal spasm:
1. Chest pain
2. Recurrent episodes of Liquid/food dysphagia - Pill-induced esophagitis:
1. Retrosternal pain
2. Sudden onset odynophagia ( difficulty swallowing)
-GERD:
1. Recurrent or persistent burning pain in upper abdomen or chest
2. Symptoms are worse following large meals or certain food (chocolate, peppermint) or laying supine
3. Symptoms are subacute to chronic
-Achalasia: (young patient + prolonged period)
1. Chronic dysphagia to both solid & liquid
2. Regurgitation
3. Difficulty belching
4. Weight loss
5. Improve swallowing on upright position
5. Due to impaired peristalsis of distal esophagus
6. Failure of lower esophageal sphincter to relax, when food bolus reach it.
7. Diagnosed with manometry (high LES pressure + incomplete LES relaxation + low peristalsis) & barium esophagram (bird beak)
8. Management: 1. Upper endoscopy (to rule out malignancy), 2. Laparoscopic myotomy or pneumatic ballon dilation, 3. Botox injection, CCB, nitrates
- Esophageal cancer:
1. Progressive solid food dysphagia
2. Unintentional weight loss
3. Types & risk factors: - squamous cell carcinoma—> alcohol/smoking —> upper esophageal
- adenocarcinoma —> Barrett esophagus, GERD, smoking, obesity —> lower esophageal
- Diagnosis with endoscopy with biopsy / CT (PET/CT) is used for staging
- candida esophagitis:
1. White plaques on endoscopy
2. Oral thrush
3. In immunocompromised - Herpes-simplex esophagitis:
1. Ulcerating lesion ( vesicles & round/oval ulcers)
2. In immunocompromised - CMV esophagitis:
1. Large linear ulcers
2. In immunocompromised
Varices (non-bleeding vs bleeding)
Non-bleeding varices prophylaxis:
1. Beta blockers (propronolol, nadolol)
Or
2. Endoscopic variceal ligation (if BB is contraindicated)
Active-Bleeding varicies:
1. Octreotide (long acting somatostatin —> function: splanchnic vasoconstriction, reduce portal blood flow by inhibiting the release of glucagon.
Cirrhotic patient
- should undergo diagnostic upper endoscopy to assess for varices & to determine their risk of hemorrhage
Management of variceal hemorrhage
Suspect variceal hemorrhage
- Place 2 large-bore IV catheter
- Volume resuscitation + IV octreotide + antibiotics (ceftriaxone)
- Urgent endoscopic therapy ( within 6-12 hours) of esophageal varieces
- no further bleeding —> BB + endoscopic band ligation (1-2 week later)
- continue bleeding —> balloon tamponade ( temporary) —> TIPS or shunt surgery
***Note: further complication of bleeding varices, include: anemia (low Hg), coagolupathy (high PT, high INR), thrombocytopenia (low platelet)
- re-bleeding —> repeat endoscopic therapy —> TIPS or shunt surgery
Esophageal perforation
Causes:
1. Post-endoscopy procedure, trauma
2. Boerhaave syndrome
3. Esophagitis
Symptoms:
1. chest, back, or epigastric pain
2. systemic signs ( fever)
3. crepitus, hamman sign ( crunching sound on auscultation
4. pleural effusion with atypical fluid (green)
Diagnosis:
- chest x-ray or CT scan —> widened mediastinum, pneumomediastinum, pneumothorax, pleural effusion
- CT —> esophageal wall thickening, mediastinal fluid collection
- esophagography with water-soluble contrast —> leak from perforation
Management:
1. NPO
2. IV antibiotics
3. PPI
4. Emergency surgical consultation
Angiodysplasia ( AVM & dilated submucosal veins))
Symptoms:
1. Recurrent, Painless GI bleeding
2. Age > 60
3. Mostly in the right colon
4. Associated with:
- renal disease ( BUN/ CR > 20)
- Von Willebrand disease
- aortic stenosis ( + bleeding can occur after Aortic valve replacement)
Diagnosis:
- endoscopic ( upper GI endoscopy or colonoscopy)
***Note: angiodysplasia can be missed with colonoscopy due to poor bowel preparation or location behind haustral fold
Treatment:
- assymptomatic —> no treatment
- anemic & occult bleeding —> treated endoscopically via cautery
Upper GI bleeding —> lead to increase BUN/Cr ration
- symptoms: hematemesis + melena + abdominal pain
- due to increase urea production ( from intestinal breakdown of hemoglobin) & increase urea reabsorption ( due to hypovolemia —> tachycardia)
Dyepepsia
Symptoms:
- epigastric pain + over-fullness + bloating during and after eating + acid reflux + heartburn + excessive burping.
- more than 1 month
Note:
- H.pylori —> is a urease-producing organism (positive stool Guaiac) —> cause peptic ulcer (dyspepsia, postprandal fullness, Nausea, GI bleeding + worsen pain during fasting & nocturnal pain)
Autoimmune atrophic gastritis
Caused by:
- autoimmune destruction of:
1. Parietal cells —> lead to hypochlorhydria & unchecked gastrin production
2. Intrinsic factors —> lead to B12 deficiency
Symptoms:
1. abdominal pain worsen after eating (postprandial)
2. Bloating
3. Elevated serum gastrin level
4. Macrocytic anemia ( high MCV, low Hg)
Familial Adenomatous polyposis (FAP)
- genetic disorder
- > 100 polyps & increase chance for colorectal cancer at an early age (< 40) if left untreated.
Management:
- elective total proctocolectomy( late teen or early 20s)
- surgery is delayed and substituted with close surveillance with frequency colonoscopy ( in children)
Gastrinoma ( Zollinger-Ellison Syndrome)
Clinical:
-recurrent peptic ulcer disease
- with multiple ulcers & jejunal ulceration
Suspected gastrinoma:
- Endoscopy shows: multiple stomach ulcers & thickened gastric fold
- Check serum gastrin level ( off PPI therapy for 1 week)
- < 110: No gastrinoma
- (110-1000): secretin stimulation test (Nogative: no gastrinoma, Positive: further test to localize tumor)
- fasting serum gastrin level (> 1000): check gastrin PH ( off PPI therapy for 1 week)
** pH < 4: further testing
** pH > 4: No gastrinoma
Common hereditary Cancer syndromes
- Lynch syndrome ( HNPCC):
- colorectal cancer
- endometrial cancer (screen endometrial biopsy 30-35 years)
- ovarian cancer ( prophylactic hysterectomy or bilateral oophorectomy at age 40) - Familial adenomatous polyposis (FAP)
- Colorectal cancer
- desmoid & osteomas
- brain tumor - Von-Hippel-Lindau syndrome (VHL):
- Hemangioblastomas
- clear cell renal carcinoma
- pheochromocytoma - MEN 1
- parathyroid adenomas
- pituitary adenomas
- pancreatic adenoma - MEN 2
- medullary thyroid cancer
- pheochromocytoma
- parathyroid hyperplasia ( type 2A) - BRCA1 &2:
- Breast cancer
- ovarian cancer
Pancreatic cyst
- mostly benign
- managed conservatively ( surveillance imaging)
- some cyst carry the risk of malignancy
- cyst with high risk features of:
- large size
- solid component or calcification
- main pancreatic duct involvement
- thickened or irregular cyst wall
**require further investigation with endoscopic ultrasound- guided biopsy & possible surgical resection
MALT lymphoma
- associated with H. Pylori infection
- patient with positive H.pylori + early stage- MALT lymphoma —> should undergo H.pylori eradication therapy.
- therapy —> PPI + amoxicillin + clarithromycin
Liver metastasis
- most common site where colon cancer metastasis to is the liver
- symptoms:
1. RUQ pain
2. Mildly elevated liver enzymes
3. Firm hepatomegaly - diagnosed with: CT of the abdomen
Malignant biliary obstruction
Etiology:
- cholangiocarcinoma
- pancreatic adenocarcinoma
- hepatocellular carcinoma
- metastasis ( colon, gastric)
Manifistation:
- painless jaundice, pruritus, acholic stools, dark urine
- weight loss
- RUQ pain
- RUQ mass or hepatomegaly
- increase direct bilirubin, ALP, GGT
Diagnosis:
- serum tumor markers ( CEA, CA-19, AFP)
- Abdominal imaging ( ultrasound, CT)
- Endoscopic ultrasound, or ERCP for tissue diagnosis if unclear
Causes of biliary obstruction
- malignant biliary obstruction
- choledocholithiasis
- benign biliary strictures
Lactose intolerance (LI)
- caused by: brush border enzyme deficiency
Symptoms:
- chronic, crampy abdominal pain
- bloating
- watery diarrhea after meals
- age 20-40
Diagnosis:
- lactose breath hydrogen test
Treatment:
- diet change
- supplementation with lactase
Post-operative period after cholecystectomy
- insufficient bile salt absorption by terminal ileum = diarrhea
- symptoms resolves within few weeks to month
PPI is associated with C. Difficle infection
C. Difficle infection lead to:
- watery diarrhea + low grade fever
- fecal occult blood testing is frequently positive (+)
Celiac disease
- autoimmune reaction to gluten-derived peptide gliadin (GDPG)
- Result in destruction of enterocytes & villous atrophy in the small intestine
Symptoms:
- fatigue + weight loss
- chronic foul-smelling, greasy diarrhea (steatorrhea)
Diagnosis:
- via D-xylose test (± assess urine & venous blood)
* patient can’t absorb D-xylose = urinary & venous blood of D-xylose is low
Note:
D-xylose is absorbed by small intestine without degradation by pancreatic or brush border enzyme —> is excreted in the urine
Exocrine pancreatic insufficiency
Seen with:
- Chronic pancreatitis
- Cystic fibrosis
- Bowel or pancreatic resection
Iron deficiency anemia (IDA)
Associated with:
1. Conjunctival pallor
2. Use of aspirin & NSAID —> lead to gastritis/ gastric ulcer —> chronic GI blood loss —> depletion of iron stores
Approach:
- Get blood count, iron studies, fecal occult blood testing
- Confirmed iron deficiency + ongoing blood loss
- Perform (upper & lower) endoscopy
Management:
- withhold NSAIDs & aspirin
- initiate PPI
Anemia of chronic disease (ACD)
- associated with inflammation
- lead to reduced red cell production by inflammatory cytokines
- related diseases: renal impairment, rheumatoid arthritis, Lupus
- signs: low iron, low TIBG, high ferritin
Aplastic anemia
- disorder of bone marrow stem cells
- induced by: exposure to drugs, radiation , chemicals, viruses
Undiagnosed hypothyroidism
- lead to fatigue, depression, mental status abnormalities, mild anemia
Nonspecific signs of anemia
- Dyspnea
- Tachycardia from hypoxemia
- Systolic murmur due to hyper-dynamic circulation
Iron deficiency anemia in elderly people
- should be investigated with endoscopy & colonoscopy
- to rule out GI blood loss ( from polyps, cancer, angiodysplasia)
- A SINGLE negative fecal occult blood test (FOBT) is not sufficient to rule out GI bleed
Melanosis Coli due to laxative abuse
- Melanosis coli is caused by several months of chronic laxative use ( anthraquinone = senna).
- colonoscopy shows epithelial damage & release of brown pigment ( that disappear when laxative is stopped) with pale patches of lymph follicles
- can be caused by: factitious disorder imposed on another
X
Clinical feature of irritable bowel syndrome (IBS)
ROME diagnostic criteria:
- recurrent abdominal pain/dicomfort > 3 days per month, for the past 3 months & > 2 of the following:
- symptoms improvement with bowel movement
- change in form
- change in frequency
Sign/symptoms associated with other diagnosis:
- rectal bleeding
- nocturnal awakening or worsen abdominal pain
- weight loss
- abnormal lab finding ( anemia, electrolyte disorder, elevated inflammatory markers)
Classification & EVALUATION :
1. IBS with constipation:
- radiography
- colonoscopy & flexible sigmoidoscopy
- IBS with diarrhea:
- stool culture
- celiac disease screening
- 24 hr stool collection
- colonoscopy/flexible sigmoidoscopy & biopsy
- mixed IBS
- Undifferential IBS
Note:
- patient with ROME 3 criteria & no alarm feature= have normal colonic mucosa & require no further investigation
Management of chemotherapy-induced diarrhea
- type: secretory diarrhea that happens during fating & causes nocturnal awakening
- via:
1. Oral hydration
2. Loperamide
3. Diphenoxylate- atropine (chemopatient)
Herpes zoster ( shingles)
-reactivation of varicella zoster virus ( spontaneous, cancer treatment, immunocompromised) due to previous chickenpox
- symptoms:
1. Pain before rash by several days
2. Visceral rash
3. Post-herpetic neuralgia
4. Age after 50
Tx:
1. Antiviral drugs
Evaluation of dysphagia
History of difficulty initiating swallowing with cough, choking, or nasal regurgitation (± ASPIRATION PNEUMONIA & weight loss):
- Yes: Likely oropharyngeal dysphagia —> video-fluoroscopic modified barium swallow
- No: likely esophageal dysphagia —>
- Dysphagia with solid & liquid —> motility disorder —> barium swallow, followed by possible manometry
- Dysphagia with solid progressing to liquid —> mechanical obstruction —> history prior radiation, cuasatic injury, complex stricture, or surgery for esophageal/laryngeal cancer —>
- yes: barium swallow, followed by manometry
- No: upper endoscopy
Note:
1. Oropharyngeal dysphagia: stroke, advanced dementia, oropharyngeal malignancy, neuromuscular disorder (MG)
Folate deficiency
- macrocytic anemia ( low Hg, High MCV > 100)
- hyper-segmented neutrophils
- normal methylmalonic acid level
- low or normal reticulocyte count
- high homocysteine
- patient with alcoholic abuse & poor nutrition can become deficient in folate in 5- 6 weeks
Inferior MI ( II, III, AvF)
Vs.
Acute pancreatitis
- can lead to epigastric pain
- rule it out in acute pancreatitis cases, by ordering troponin
- ercp: MORE THRAPUETIC THAN DIAGNOSTIC
-MRCP:
Admit patient to ward or ICU
- fluid 5-10 of isotonic crystalloid solution
- lactate ringer is contraindicated in acute pancreatitis related to hypercalcemia
- heart failure & compartment syndrome can result from not restricting fluid in patient with acute pancreatitis within 48 hours
- if patient cant tolerate food after 48 hours —-> provide feeding via enteral (nasogastric tube)
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